2 Executive Summary 1 This is the first presentation to Trust Board of the OUH Nursing and Midwifery Strategy. 2 This Nursing and Midwifery strategy is aligned to the values of the Trust and other key Trust Strategies such as the leadership, recruitment and retention. 3. The goal of the Nursing and Midwifery Strategy is to ensure; Outstanding Nursing and Midwifery practice with an internationally recognised reputation for excellence. This will be achieved through five strategic themes which are: 1. Excellent nursing and midwifery clinical practice 2. Career enhancing education and professional development 3. Leading practice development and research 4. Exceptional Nursing & Midwifery Leaders 5. Innovative nursing & midwifery models for the future. 4. Over 150 nurses were involved in the consultation process for the strategy. The focus groups were attended by nurses in Band 5 through to Band 8. The feedback provided and themes discussed as part of the consultation and scoping of the strategy set the foundation for developing the strategy. This was framed in the context of national and international work in this arena. 5. A summary implementation plan has been developed in order to progress some of the short term aspects. A similar strategy will be developed with Allied Health Professionals in Recommendations The Trust Board is asked to endorse the OUH Nursing and Midwifery Strategy , and associated streams of work in this area. Nursing and Midwifery Strategy Page 2 of 13

3 THE OXFORD UNIVERSITY HOSPITALS TRUST NURSING AND MIDWIFERY STRATEGIC PLAN Introduction 1. The purpose of this paper is to outline the Nursing and Midwifery Strategy for Oxford University Hospitals (OUH) Trust for This has been developed based on consultation which elicited the views of over 150 nurses and midwives across all Trust sites. They have been fundamental in the creation of the strategy and have also assisted in identifying the proposed strategic themes for the next three years. 2. Feedback on the current situation and a summary of ideas were received as part of the consultation. Some of the perspectives of those involved have been included below in order to illustrate strength of feeling, engagement and alignment by nurses and midwives who supported this body of work. The priorities have been developed based on the initial broad themes discussed in the consultation and then refined into five key strategic themes. 3. Although initially these themes were built from the consultation they were subsequently reviewed based on consideration of the national and local context and models of national and international best practice. Background 4. Oxford University Hospitals (OUH) Trust has a long-standing international reputation for the exceptional quality of medical care, medical education and scientific research. Many of the participants in the consultation resonated with the views of external professional bodies that during the 1980s Oxford led the way in nursing practice development and innovation in the UK and beyond. Notable examples of this were the implementation and development of Primary Nursing, the Nursing Development Units, the role of the Clinical Nurse Leader, pre-registration education to degree level and the first joint appointments in the form of Lecturer Practitioners. 5. There was considerable feedback during the consultation that, within the last 10 years, the momentum had been lost and OUH has lost its reputation as a world leading centre for exceptional nursing and midwifery practice. This was felt to have been overtaken by a number of other centres which occupy the world stage in relation to excellence in nursing and midwifery leadership and care. 6. In common with many other organisations in the NHS, OUH has significant nursing retention and recruitment challenges. There was a consistent view expressed that these challenges may be compounded by a perceived lack of innovation, opportunity for education, practice development and limited focus on opportunities in nursing and midwifery care. 7. There have been three aspects to the development of this strategy: A review of the national and local data on nursing and midwifery. Consultation with key nursing and midwifery staff across all sites and levels including representation from international staff. Nursing and Midwifery Strategy Page 3 of 13

4 Discussion with senior nursing and midwifery staff to ensure the key themes were challenged and professionally aligned to the Trust s values. Nurses and Midwives at OUH Trust 8. A suite of demographics for nursing, midwifery (and those staff who are generally aligned to nursing and midwifery) in the Trust were considered to provide the context of working within OUH. The headcount of the total group (nurses, midwives and clinical support workers) represents almost half of the workforce within the Trust (Table 1). Therefore, a strategy that resonated with this portion of the workforce could have broad benefit for the organisation. 9. A focus on these professions was based on some of the feedback received from the focus groups where participants felt strongly that any strategy should reflect key themes for the Trust and reflect professional and career interest. The 2014 review by the Advisory Board on international innovations that support Energising the Nursing Workforce found from its global review that 54% of nurses align most strongly with their profession compared to 12% with their organisation. Table 1 number of nurses and midwives, clinical support workers by headcount Heads Unregistered Qualified Band Band Band 4 67 Band Band Band Band 8a 48 Band 8b 34 Band 8c 5 Other 1 Senior Manager 2 Grand Total Table 2 number of nurses and midwives with honorary contracts by headcount Honorary Nursing & Midwifery Headcount Nurses 237 Midwives 9 Grand Total The table above (Table 2) illustrates the number of nurses or midwives with honorary contracts known in the Trust which appears to be related to medical research undertaken in the Trust. There is expected to be a substantial underestimation of the total number of nurses who work aligned to OUH with Oxford University or other funders such as commercial research partners. Nursing and Midwifery Strategy Page 4 of 13

5 11. This is in contrast to the very limited infrastructure or opportunities for nursing or midwifery staff who wish to undertake explicit Nursing or Midwifery research. Initial scoping is being undertaken and progressing rapidly with the support of Health Education Thames Valley (HETV) joint appointment of a Professor of Nursing between OUH and Oxford Brookes University. There has been support and collaboration from the Academic Health Science Centre (AHSC), Academic Health Science Network (AHSN) and Biomedical Research Centre (BRC). Table 3 percentage of nurses and midwives by age as proportion of headcount <21 0.0% 2.1% Age Profile by Headcount 4.8% 10.1% 12.0% 12.0% 13.3% 13.3% 16.2% 16.1% 0.0% 5.0% 10.0% 15.0% 20.0% 12. Table 3 shows the age profile for nursing and midwifery in the Trust. This data is consistent with the national and international picture. There are broader system impacts such as the retirement age of nurses, 55 years of age. 13. The impact of the shape of the workforce age profile is important when considering ways of growing and retaining the best as part of the strategy. This has reinforced the need for a targeted approach to some aspects of retention programmes. It is important that initiatives reflect the aspirations and professional development needs within the whole career cycle as well as articulating with the Trust s priorities to provide excellent patient care. 14. The staff survey and the consultation process suggests that nurses in the early part of their career (those up to age 30 years) are attracted by the promise of the Trust s work environments, where there are opportunities to increase their clinical skills and competence and which offer diversity in practice in order to build their knowledge. This group are likely to hold the talent pool of locally developed future clinical leaders. Therefore this group will benefit from clinical supervision to support skills development, options for gaining expertise and initial clinical leadership experience which may encourage a longer commitment to the Trust. This group comprises approx. 26.6% of the OUH workforce and this group are also in the age range of highest turnover and shortest length of employment. 15. Those nurses in the age range represent 28.1% of the workforce and those years represent 32.3%. This group have different career aspirations that may be linked to recognition of experience, broader clinical, education or management leadership opportunities. The data also suggests that those over 50 years represent Nursing and Midwifery Strategy Page 5 of 13

6 17% of the workforce and may be considering options to retire when they are able. This is mirrored in the national data but is lower that some other developed countries (HWA 2013). Specific strategies that support their retention or transition to retirement will be developed in partnership with the Workforce and Organisational Development Directorate. Options for flexible transition to retirement have been successful in other health systems and could be considered in OUH. Table 4 percentage of nurses and midwives by length of service as proportion of headcount Length of Service 5 + Years 4-5 Years 3-4 Years 2-3 Years 1-2 Years 6-12 Months 0-6 Months 0.0% 10.0% 20.0% 30.0% 40.0% 50.0% 60.0% 70.0% 16. The largest group in terms of age range is the age range (32.3%) as shown in Table 3. This group are broadly those who have been employed in the Trust for the longest time (see Table 4). This group of nurses and midwives provide the continuity and expertise required for the foundation of an outstanding nursing and midwifery service. This strategy will need to reflect initiatives that recognise the individual s expertise and build upon their clinical and leadership skills, thus ensuring their practice remains contemporary. Of nursing and midwifery staff, 60% have continuity of service of five plus years and this is generally positive. However, the 25% of staff (mainly in the younger age group) that remain less than two years create instability in the system and this can undermine the aspiration of excellence and put additional pressure on the experienced staff to provide preceptorship support and clinical supervision. 17. Workforce performance data for OUH Trust Quarter 3, 2014/2015 indicates that the vacancy rate for nursing and midwifery is 15.7%. This is significantly higher than the Trust average for the quarter of 6.9%. The sickness rate for nursing and midwifery is 4.0% against a Trust average of 3.7%. The turnover rate indicates that allied health professionals have the highest turnover rates, however, the turnover for nursing is 13.9% accounting for 38% of all leavers in the Trust. This is most significant in the Band 5 group where the turnover rate is an average of 17.9%. 18. The Nursing and Midwifery Strategy aligns with the OUH Trust Retention and Recruitment Strategy and will focus on those factors across the Trust that influence nurses and midwives decisions to seek employment at OUH Trust or to make a longer commitment to the Trust. The strategy will support a unique opportunity to build the Nursing and Midwifery Strategy Page 6 of 13

7 capacity and capability of the organisation which fundamentally has a positive effect on the quality and safety of patient care. Developing the Strategic Goal and Themes Consultation 19. The development of the OUH Nursing and Midwifery Strategy was based on a bottom up approach and seeking the views of all groups of nursing and midwifery stakeholders. The focus groups with all levels of the professions formed the cornerstone of this work, which was well received. In addition to this there were specific senior nurse groups to explore emerging themes, which was supported by external facilitation. The participation of a Non-Executive Director in this event also supported the Trust s commitment to developing the strategy. 20. Although the participants were largely self-selecting, the staff appeared enthusiastic about the vision and keen to play their part in developing OUH as a leading centre for nursing and midwifery in the UK, with an outstanding international reputation. Nurses and midwives at OUH are also excited that the notion of being the best is quantified, hence their keenness to participate in an international recognition / accreditation programme such as Magnet. However, all of the hallmarks and criteria for being the best and gaining accreditation are the elements of best practices that a leading Academic Health Centre, such as OUH, should aspire to. There was consensus that nurses and midwives would like to strive for outstanding care and clinical practice underpinned by education, practice development and research endeavour for the benefit of patients and the community. The quote below from one of our Band 5 Registered nurses reflects the views of many of those attending. They were keen to build a culture, and capability, along with a brand of OUH Nursing and midwifery that reflects their expectations. I remember someone from HR telling us how Oxford is number one for research but the reality is that there is No nursing research so we re not number one. We did more at the DGH I worked at and we had more and much better training opportunities. I want to do my Master s but I don t see much hope.. I want it to work and want to work here but there are plenty of other places (Band 5) Academia has made me professionally and intellectually secure but I don t see people now being offered these opportunities. I firmly believe that the artistry of nursing is with the experienced, Master s graduate Ward Sister (Band 7) 21. The themes and characteristics of an outstanding nursing and midwifery service were explored in the focus groups. The way in which nurses and midwives expressed their concerns and how to achieve the goal of Outstanding Nursing and Midwifery with an international reputation was slightly broader than the final refined suite of strategic themes that have been developed. Without exception all the participants were aligned on the key issues and how to progress the strategy. 22. The comments made suggested a need to build a reputation that showed that there was something special, exceptional and outstanding about being an Oxford Nurse. They expressed a need for effective and influential leadership (executive level specifically), motivated and engaged nurses and midwives at all levels who have appropriate education and training. Appraisal was seen as key and nursing sensitive Nursing and Midwifery Strategy Page 7 of 13

8 clinical outcomes benchmarked as part of continuous quality improvement processes was essential to build the culture of improvement, innovation and evaluation of care. 23. Although the characteristics were expressed in different ways in the focus groups there was absolute consistency between all staff groups. Reassuringly for the Trust, the goals of those nurses and midwives participating in the development of the strategy are aligned with the strategic workforce and quality imperatives for the Trust. The identified themes for the next five years are consistent with the values of the Trust and the NHS England s Five year forward view. 24. There was a strong commitment to personal, professional and organisational endeavour and ambition of those involved in the focus groups, and all of the senior nursing teams. The strategy is aimed at harnessing the initial enthusiasm for excellence and building on this incrementally to ensure sustainable programmes of work over the next four years. The strategic goal for Nursing and Midwifery at OUH Trust was expressed as: Outstanding Nursing and Midwifery that is internationally recognised for excellence 25. This will be underpinned by strategic themes that establish the foundations of clinical excellence, leadership, research, innovative models of care and education that provide outstanding nursing and midwifery practice. 26. The strategic themes reflect contemporary nursing and midwifery practice which are often the focus of an internationally renowned nursing service. These are seen as important for patients, communities and the professions. The strategic themes are: 1. Excellent nursing and midwifery clinical practice 2. Career enhancing education and professional development 3. Leading the way in practice development research 4. Exceptional Nursing & Midwifery Leaders 5. Innovative nursing & midwifery models for the future. Nursing and Midwifery Strategy Page 8 of 13

9 Exceptional leaders Excellence in practice OUH Outstanding Nursing and Midwifery Career Enhancing Education Innovative models of care Leading Research 1. Excellent nursing and midwifery clinical practice OUH nurses and midwives are committed to provide extraordinary clinical practice, which reflects the needs of our patients, families and the community. This will be achieved through supporting professional growth ward based quality improvement and innovation that supports patients experience, and quality of care. Key drivers to support this will include revalidation, consistency in clinical nursing policy and protocol development, assessment of contact hours of care to meet personalised needs of patients and research that reflects nursing practice that improves care. Quality improvement strategies will include striving for consistent clinical practice that maximises the feeling cared for experience for patients built on a foundation of competent and confident, professionally curious nursing and midwifery professionals. 2. Career enhancing education and professional development The sustainability of the nursing and midwifery workforce is essential for the delivery of high quality, effective health care. A suite of initiatives is in development which is founded on creating a thriving professional workforce environment. This needs to be an essential pillar of nursing and midwifery at Oxford. Strategies will focus on creating an education and training infrastructure, in partnership with the Workforce Directorate, which creates career appropriate education and professional development options. The focus on education and training will ensure options that support and encourage early career nurses seeking to build skills and diversity, along with experienced nurses who may wish to have additional challenge and extension of their clinical role. Additionally initiatives will also seek to meet the need of those nurses who may seek transition to retirement and could provide clinical coaching for the broader workforce. Nursing and Midwifery Strategy Page 9 of 13

10 A goal of this part of the strategy is to build on the smaller Education and Training Academy currently in place for clinical support workers. This will create a focus that supports professional nurses and midwives throughout their career and creates pathways for unregulated staff that builds on Oxford s reputation and is recognised nationally. Specific work has commenced on a Foundation Programme for new graduates who are seeking structured education, support and clinical supervision. There has been initial success, which is very positive. This is currently being broadened to support new EU post induction nurses and the development of OUH priority skills. 3. Leading the way in practice development research During the focus groups and at the broader Nursing Research Forum with research nurses at OUH held in November 2014, there was overwhelming enthusiasm and passion for nurse led research that focuses on patient experience, quality of care, families and the contribution to the broader health agenda by nurses and midwives. Currently the Oxford wide health economy includes substantially lower numbers of nurse researchers than within other University Hospitals (Shelford and others), with the first professor of nursing having just being appointed in approximately 20 years. The key drivers that will be used to support the development of emerging nurse researchers include the appointment of a Head of Nursing Research (HETV supported) and the establishment of an alliance within the AHSC for Nursing, Midwifery and Allied Health Research. Key partners have committed to building clinical academic careers through bursaries and fellowships. This strategic focus has commenced and would also be expected to support the evolving national reputation for the Trust as the programme develops. 4. Exceptional Nursing & Midwifery Leaders The challenges of 21 st century health care, with the complexity of multiple comorbidities, the electronic health care agenda and changing consumer expectations, requires nurses and midwives who understand the regulatory, quality and integration of care requirements for patient care. This strategic theme will support building courageous and influential leaders who have developed foundation management and leadership skills across their career. This will be established in parallel with a robust succession planning and talent management programme that can be maximised in partnership with the Workforce Directorate. In the OUH Trust nurses and midwives at Band 7 Sister level are accountable and manage teams of staff, budgets of approximately 2 million with a highly vulnerable customer group of patients and families. This key role in the organisation is accountable for quality of care, patient experience and other key indicators of performance and finance. In order to meet the Trust s strategic imperatives this group of clinical leaders requires a combination of structured and work based management and leadership programmes to build their skills and confidence. Nursing and Midwifery Strategy Page 10 of 13

11 Succession planning through exposure to structured programmes of immersion into senior leadership roles such as shadowing and broader networking will also support the organisations capability. 5. Innovative nursing & midwifery models for the future Nursing and Midwifery, as the largest professional group, are well placed to progress models of care that maximise every professions skills and support advanced practice that adds value for patients and the Trust. There are emerging advanced practice models and new models of nursing care that can improve patient care and also contribute to the broader integrated care and public health agenda. Key to this will be ensuring that nurses and midwives work to the top of their licence. Some of the actions that will support this role enhancement include consideration of how unregistered roles can provide additional opportunities, where nursing and midwifery can add value within the care continuum, and consideration of the education needs to drive changes. 27. Each of these themes is aimed at building a culture of clinical excellence and successful professional endeavour that support the Trusts goals of delivering compassionate excellence. Creating momentum and recognising progress in each of these themes will be a core enabler for building this culture. Implementation 28. Given the urgency of progressing some of the aspects of the strategy in light of the recruitment and retention issues for nursing and midwifery, some work within each of the themes has already begun. Although there may be some short term impact from increased focus and communication as part of establishing the strategy, the greatest benefits will be achieved incrementally over the four year time frame (Appendix 1) as each of the strategic themes are rolled out across the Trust and become embedded in the organisation. 29. In order that the entire programme is measurable against international best practice it is proposed to use international nursing accreditation standards as a vehicle for transformation. Initial work has been undertaken to benchmark against the requirements to participate in the Magnet programme, however, other recognition and accreditation programmes are also being explored and will be provided to the Trust Board for consideration when a detailed analysis is competed. 30. A key milestone is to launch the OUH Trust Nursing & Midwifery Strategy on International Nurses Day, 12 May 2015, as part of the Inaugural Nursing Research Conference, which will take place at OUH, along with a series of other events recognising outstanding nursing and midwifery practice. 31. The strategy is a very large and complex programme of work. It is proposed that a facilitated Programme Management approach be taken with a Nursing and Midwifery Leadership Programme Delivery Board established to provide oversight over each of the five work streams with clear timelines, milestones and key deliverables. Two of the key milestones for 2015 have been achieved with the appointment of a Head of Nursing Research and interim Head of Nursing Education. These roles are reviewing Nursing and Midwifery Strategy Page 11 of 13

12 current status of their portfolios and identifying opportunities for improvement to meet the Strategies goal. 32. Consistent with the inclusive and engaging approach that has been taken so far, it is proposed that the leadership of these groups is facilitated and that a range of nurses and midwives are involved in order to inform the delivery of the strategy and support succession planning and their own professional development. Resource implications 33. The majority of this programme will be managed within existing resources, however, nurses and midwives and key stakeholders will need to engage with the process which will require a commitment in time. As key elements of the strategic themes are refined further business cases will be developed as required, particularly in the areas of education and research. However, alternative revenue streams are being explored in order to create financial sustainability for these themes. Development of an education and research programme will require a review of the current infrastructure for nonmedical education and research. The Executive Director of Organisational Development and Workforce is currently also reviewing education requirements as part of the Education and Training Strategy. Oxford Brookes University is currently partnering with OUH, Oxford Health (OH) and HETV to establish a Nursing and Midwifery Research Alliance, which may require consideration of financial business case in the future. Assessment of suitability to progress Magnet or a similar UK based accreditation process will require concentrated focus by a programme manager and commitment to participation in the programme. Evaluation and Research 34. Evaluation of the impact of undertaking a structured pathway to achieving a nursing and midwifery strategy will be included as part of the overall programme. Success of the strategy will be measured against key international benchmarks for high performing nursing services. Initial assessment against these has commenced to identify the specific metrics to be measured. 35. National metrics of success will be measured. This will include but not be limited to quantitative metrics such as turnover rates and the qualitative analysis of exit interviews, nurse engagement, etc. 36. Quality metrics that are considered to be nurse or midwifery sensitive quality indicators will be measured regularly pressure ulcer, falls, etc. Professional development, research and education will be measured against key international metrics such as successful completion of additional education and training that meets patients needs, publication of nursing and midwifery research and implementation of innovative models that have improved care. These metrics will be provided to Trust Board as part of a regular report. Nursing and Midwifery Strategy Page 12 of 13

13 37. In order to meet the goal of building an international reputation assessment will be benchmarked nationally and against international measures of success such as the Magnet criteria and framework for accreditation. Conclusion 38. OUH Trust has the opportunity to lead the direction for nursing and midwifery locally and within the national context. There are benefits in terms of workforce retention and attraction, improved patients outcomes and building a reputation nationally and internationally. The Trust is fortunate to have a base line of experienced nurses and midwives in addition to enthusiastic junior staff. Success will require a commitment at all levels of the Trust to drive forward some of the fundamental practice changes, leadership development, education, training and research requirements needed to meet the strategic goal of an outstanding nursing and midwifery service that is internationally recognised for excellence. Recommendations 39. The Trust Board is asked to approve this challenging strategic work which is supported by nurses and midwives throughout the Trust. There is the desire to transform care for the benefit of patients, and also to enable the Trust to build an international reputation as a leader in nursing and midwifery. Catherine Stoddart Chief Nurse March 2015 Nursing and Midwifery Strategy Page 13 of 13

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